Doctors lag in dietary training, research shows

Published: April 13, 2013

Despite a growing consensus that cardiovascular disease is a “food-borne” illness, many physicians are ill-prepared to advise patients on what they should eat to best protect them from heart attack or stroke.
One provocative new study found that a Mediterranean-style diet was so effective at warding off heart attacks, stroke and death that scientists stopped the study early. They wanted to let subjects in the control group and the public start to reap the benefits.
Yet the number of hours devoted to nutrition education in medical schools is decreasing, leaving doctors unequipped to deal with common patient concerns about diet, studies have found.
Even as rates of obesity and Type 2 diabetes soar, researchers report that doctors are spending less time than ever talking to patients about nutrition because they lack time, training and optimism that patients can make lifestyle changes. Insurance is also more likely to cover procedures than behavioral counseling.

“Ask 50 cardiologists and they'll say, 'Of course I know about the Mediterranean diet,'” said Dr. Dean Ornish, president and founder of the nonprofit Preventive Medicine Research Institute. “But if you ask, 'Do you teach it?' they say, 'No, who has the time?' This is real-world medicine. We need to do it better.”
“There's tremendous ignorance about nutrition among physicians,” added Dr. William Davis, a preventive cardiologist in Milwaukee. “It has never been part of the culture.”
Cardiovascular disease, which kills 600,000 Americans a year -- more than all types of cancer and AIDS combined -- is linked to high blood cholesterol. Though cholesterol-lowering statin drugs are popular treatments, levels in the body also can be lowered through diet.
Meanwhile, lifestyle changes have been shown to work better than medication in preventing obesity and Type 2 diabetes, both risk factors for heart disease.
Research suggests that physicians don't feel comfortable, confident or adequately prepared to give nutrition advice, said Kelly Adams, a research associate in the department of nutrition at the University of North Carolina.
On average, doctors receive 19 hours of total nutrition education in medical school; in 2004 the average was 22.3 hours, according to the study, conducted as part of the Nutrition in Medicine project at UNC. In 2009, 27 percent of the schools met the minimum standard of nutrition training, compared with 38 percent in 2004.
Ben Kester, 25, who is finishing his second year at the Northwestern medical school, said nutrition has been mixed into some of his classes; in a recent cardiology unit, the class talked about using statin drugs in combination with diet as the first line of treatment, he said.
Learning about nutrition is important, he agreed, but it also can fall by the wayside amid other demands. Medical school can be so stressful that, often, “our own eating habits are the first thing to go,” he said.
Though several diets can benefit heart health, a systematic review ranked the Mediterranean diet as the most likely model to provide protection against heart disease. The Lyon Diet Heart Study previously showed that it could reduce the risk of a second heart attack by up to 70 percent.
The traditional Mediterranean-style diet is characterized by high intake of olive oil, fruits, nuts, vegetables and cereals, moderate amounts of fish and poultry and low doses of dairy products, red and processed meat, and sweets. Consuming wine at meals in moderation, exercising and relaxing with friends are also considered important elements.
The heart-healthy mechanism is still a mystery, but evidence suggests the diet is anti-inflammatory and helps improve the function of endothelial cells, which pump out nitric oxide.
“Nitric oxide keeps cells within our blood vessels flowing smoothly, prevents inflammation from developing in the walls of the arteries, keeps us from getting stiff vessels and has a role in keeping us from developing blockages or plaque,” said Dr. Caldwell B. Esselstyn Jr., author of “Prevent and Reverse Heart Disease.”
For the recent study on the Mediterranean-style diet, published last month in the New England Journal of Medicine, researchers in Spain randomly divided patients who were already at high risk for heart disease into three groups. One was given a low-fat diet and advice on how to follow it.
The other two groups were placed on a Mediterranean diet, with one using at least four tablespoons of extra-virgin olive oil per day for cooking and dressing food. The third group was told to eat an ounce, or a generous handful, of a combination of walnuts, almonds and hazelnuts per day.
The volunteers in both Mediterranean diet groups had a “substantial reduction in the risk of major cardiovascular events among high-risk persons,” the researchers concluded.
For Jessie Chavez, 39, a software engineer for Google, heart disease loomed in his future. His father had three heart attacks -- the third was fatal -- and Chavez, who worked long hours at the computer and neglected his diet, had high cholesterol.
Initially his doctor put him on a statin drug. But when he asked if there was anything more he could do, “she said, 'Well, of course you can look into diet,' but I felt like she didn't see it as something viable,” Chavez said.
Chavez went to see Devries, who incorporated a Mediterranean-style diet and exercise into his heart health program. Chavez, 5 feet 10 inches tall, dropped his weight from 196 to 156 and is now off nearly all medication because his cholesterol is back to normal. Once physically unfit, he's now able to run 10 miles.
“As an engineer, I always think, 'Where's the proof?'” said Chavez, of Berwyn, Ill. “To actually have a cardiologist tell you, 'Here are a few studies, this is what it shows and this is the impact' gives you more options. I liked knowing it wasn't part of a fad, but science.”
MEDITERRANEAN DIET: A SAMPLE MENU A Mediterranean-style diet emphasizes foods traditionally consumed in countries bordering the Mediterranean Sea. Here is a sample day's menu provided by Dr. Stephen Devries, executive director of the Gaples Institute in Deerfield, Ill., which promotes the value of nutrition and natural strategies in medical care.
Breakfast:
Yogurt parfait: Layer fat-free plain Greek yogurt with blueberries or strawberries. One teaspoon honey optional.
Or: 100 percent whole-wheat English muffin topped with one tablespoon almond butter and a cup of blueberries or strawberries.
Water (best option) or ½ cup of juice. One cup coffee or green tea.
Midmorning snack:
Apple, orange or pear.
Lunch:
Spinach and kale salad with a wide variety of colored vegetables, dressed with balsamic vinaigrette, and topped with either walnuts and feta cheese or chicken breast.
Small slice of 100 percent whole-grain bread or pita.
Sparkling water with slice of lemon or lime.
Mid-afternoon snack
Handful of almonds, green tea.
Dinner:
Grilled wild salmon, ¼ cup of quinoa with rosemary and pine nuts, grilled cauliflower/broccoli/carrots drizzled with olive oil.
Spinach and kale side salad with vegetables and balsamic vinaigrette.
One glass of wine if desired. Sparkling water with slice of lemon or lime.
Sliced fresh fruit.